A glance at how hospitals can maximise infection control practices while maintaining efficient cleaning systems.

Housekeeping in hospitals is all about cleaning and disinfecting environmental surfaces – the ones that everybody touches with dirty hands. The contamination and cross contamination of environmental surfaces in hospitals, such as door knobs, hand rails, chairs and tables, play an important role in the transmission of a wide range of microbes that cause nosocomial (hospital acquired) infections. Pathogens such as Norovirus, Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus spp (VRE) are well-known environmental contaminants. They survive for prolonged periods of time in the environment,

from hours to days, and in some cases even months. Healthcare professionals, visitors and other patients then spread these microbes to even more surfaces and areas. In many cases, the extent of patient-to-patient and patient-to-healthcare worker transmission has been found to be directly proportional to the level of environmental contamination and effectiveness of cleaning.

The need to clean 

Improved cleaning and disinfection of environmental surfaces and effective hand hygiene have been shown to reduce the spread of all of these pathogens. Importantly, some pathogens, such as Norovirus and C difficile, are becoming resistant to the most common surface disinfectants, so the latest enhancements in cleaning practices are required.

While current hand hygiene guidelines and recommendations for surface cleaning/ disinfection should be followed in managing outbreaks, an easy enhancement to the normal daily cleaning program can reduce cross-contamination in the hospital environment whenever a pathogen outbreak is likely (seasonal outbreaks), or known, to be occurring. Specifically, the frequency of cleaning of the various higher risk surfaces needs to be increased. Changing to a higher level disinfectant may also be required for some pathogens such as Norovirus. High-risk hand contact surfaces are the first surfaces to get contaminated, so increasing the frequency of disinfection of these surfaces goes a long way to reducing the further spread of infections throughout facilities.

Unfortunately, routine and terminal cleaning of room surfaces by environmental services personnel and medical equipment by nursing staff is frequently inadequate. Many studies have shown that less than 50 per cent of hospital room surfaces are adequately cleaned and disinfected with the usual chemical germicides. In most cases, the lack of thoroughness of the cleaner is the cause of the poor level of disinfection, though insufficient effectiveness of the germicide is becoming another significant factor. Similarly, inadequate cleaning of wheelchairs, walkers, and physiotherapy equipment has also been shown to be a problem leading to poor overall disinfection results.

Studies show that cleaners often fail to clean 100 per cent of the surfaces of over-bed tables, bed rails, and similar objects; 80 per cent wiped is not sufficient to prevent the spread of pathogens. More importantly, the 80 per cent that was wiped was most often done too quickly, failing to allow sufficient dwell time for the disinfectant to work effectively, in accordance with manufacturers recommended contact time to inactivate microbes.

The implementation of improved staff training, supervisor checks and checklists, and methods to measure the effectiveness of room, surface and equipment cleaning (eg., use of ATP detectors or fluorescent dye), with immediate feedback to environmental services personnel, has been found to improve cleaning and lead to a reduction in healthcare-associated infections.

Establishing a system

With the new economic reality upon most of us, there is pressure to clean hospital areas and patient rooms more quickly, using fewer people, and smaller budgets. Rushing cleaners and cutting corners leads to reduced effectiveness of disinfection and poor infection control outcomes. An interim solution is an infection control risk rating system that looks at the minimal, or preferably optimal, level of cleaning required for each room in an area. Higher rated areas would get the optimal level of preventative disinfection, while low risk areas would receive little or none.

Usually a ‘hotel clean’ level of cleaning is sufficient for general public area, storage areas, and office areas. However, higher risk surfaces, such as corridors in patient areas, frequency-used equipment such as wheelchairs or BP meters, and hand contact surfaces in high risk areas, require more frequent and thorough preventative disinfection. The practice of increasing environmental disinfection rounds of frequent hand contact surfaces is a good interim method of reducing the general ‘load’ of potentially pathogenic microbes when budget factors force a reduced effort in the many patient areas. Frequency of disinfection for some surfaces in high risk areas may reach 2-3 times a day, when deemed necessary. And ‘when necessary’ is a key point, decided upon by a well-informed manager at the request of the infection control practitioner. When practiced effectively, there should be a dramatically reduced need to undertake the much more thorough and resource intensive disinfection of patient rooms and outpatient areas that have few current risks. This is especially true when normal protocol calls for surrounding-area de-contamination efforts whenever a single room is identified as colonized by pathogenic microbes.

Cleaning tools

Microfiber systems using new technology mops and hand cloths are particularly effective tools for all infection control toolkits. These tools zap microbes electrostatically or adsorb them tightly bound to the microfibers. Microfiber products can be used wet, with or without disinfectants, or can be used dry in many applications, further reducing the opportunity for environmental survival or growth of microbes.

Use microfiber dry mopping where possible instead of wet floor machines. When you do need to use floor scrubbing machines, be sure to maintain the squeegee wipers that collect the soiled water, vacuuming the floor to near dryness. Floors that take more than a minute to dry will support the survival, growth and spread of microbes throughout the facility. When considering the overall healthcare environment, remember to stay aware of furniture and equipment movement within the facility. Often a patient bed is removed to a maintenance area for repairs, remaining in a dirty area for weeks, awaiting new parts. When this bed is returned to the bed holding area, it requires a much more thorough cleaning and disinfection before being placed in a patient room.

Awareness, training, effective supervision, and monitoring will improve your infection control outcomes. Want a better result for your entire infection control programme? Then use designated personnel, trained at a higher level for key high-risk areas. Develop these staff with a career management program that motivates and rewards them with growth opportunities. This provides you with better commitment and a continuous improvement system to ensure the best disinfection outcomes.

About the author:

Brian Prystupa is a Division Manager at Reza Hygiene, where he works as a microbial control specialist, an industrial hygiene consultant, and food safety trainer for hundreds of food industry clients. Brian enjoys helping companies to develop cost-effective industrial hygiene programs, to reduce the consumption of water and chemicals, and to implement waste reduction and recycling programmes.